Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 30.024410 | OH |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 30.024410 | OH |
NPI | 1295908028 |
---|---|
Provider Name | Dr. Lauren Graham Bourell |
First Address | Sylvania, OH 43560-2736 |
Second Address | Sylvania, OH 43560-2736 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2008 |
Last Update Date | 01/08/2019 |